(HESI PREP) The Nursing Process

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data?

"Client seems very nauseated." This statement is subjective because it is the nurse's interpretation. The other options are incorrect because they reflect objective data.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take?

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. When equipment is not readily available, it can be tempting to use work-arounds. Although down-time procedures may exist that allow for printing of the medication record, this is not the problem the student is facing. The student should make every effort to obtain the computer so the electronic medication record can be used appropriately for medication administration. Speaking to the instructor in advance, rather than afterwards, demonstrates superior communication and problem solving skills.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent. All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool." Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

The nurse is caring for a client who is recovering from a moderate sedation procedure for closed reduction of a forearm fracture. The nurse includes what discharge instructions for this client?

"Do not make any important decisions or sign any important papers for the next 24 hours." Discharge instructions following moderate sedation direct the client not to make any important decisions or sign any papers for 24 hours, as the medications given for the procedure can cloud judgment and impair decision making. The client would be encouraged to rest for the remainder of the day, and would not be encouraged to return to work. Clients should refrain from driving or operating heavy machinery for 24 hours, not 5 days, after receiving moderate sedation. Clients can take prescribed pain medications or over-the-counter medications, as recommended by their healthcare provider, and do not need to wait 24 hours.

The nurse enters a client's room and finds the client slumped over in a chair. What actions would the nurse take? Place the steps in the correct order from first to last. All options must be used.

Establish unresponsiveness. Confirm there are no respirations. Call for the resuscitation team. Place the client on a firm surface. Deliver 30 chest compressions at a rate of 100 per minute. Have a second person deliver 2 rescue breaths for each 30 compressions. According to American Red Cross, the nurse should first establish unresponsiveness. After unresponsiveness is confirmed, the nurse should confirm there are no respirations. If the client is not breathing, the nurse activates the resuscitation team. Next, the nurse places the client on a firm surface. If there is no pulse, the nurse begins cycles of 30 compressions and 2 breaths, ideally with a second person using a bag-valve mask to deliver the breaths. The rate of compressions should be about 100 per minute.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

"I need to inform you that your behavior is within the definition of assault." The nurse's response is threatening and could legally be interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding the comments and potential actions. The other options do not represent appropriate interventions for the scenario described.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior. Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask?

Are you comfortable performing the tasks assigned? Because the float nurse is not familiar with staff, it is important to ask the other staff if they are comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care. Asking the highest educational level, how long they worked on the floor, and personal preference is not as important as if they are comfortable with performing the task.

A nurse at a healthcare facility has just reported for duty. What should the nurse do to ensure maximum efficiency of change-of-shift reports?

Come prepared with the material required to take notes. The nurse should come prepared with material required to take notes during the change-of-shift report. The nurse should not delay the meeting for change-of-shift report by speaking to each staff member individually. Change-of-shift reports are not normally conducted in the presence of physicians; hence, the nurse need not wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

Which source of information helps a nurse formulate nursing diagnoses for a specific client?

Essential assessment data The nurse formulates nursing diagnoses after completing the assessment or data collection step in the nursing process. Analyzing essential assessment data and identifying the specific signs or symptoms and probable cause help the nurse diagnose the client. Research articles provide information related to developing current interventions, but they don't help the nurse formulate nursing diagnoses. The nurse formulates outcome criteria after (not before) nursing diagnoses. Admission criteria may help her formulate the diagnoses but won't do so without essential assessment data.

The nurse is giving a 40-year-old client with limited English language skills printed information about postoperative dressing care. The nurse is using the interpreter to explain the printed information. What should the nurse do to determine that the client understands the procedure?

Have the client demonstrate how to change the dressing. The client will demonstrate understanding through a "teach back" approach. The nurse is also available to answer questions that may arise. The level of education achieved is not an indicator of ability to read a second language. Administering a pre-test or post-test of knowledge is inappropriate if the client cannot read the document printed in English. Having the client review the materials and ask questions is not appropriate if the client cannot read the information.

A newly admitted client in a skilled nursing facility has diabetes and is experiencing episodes of hypoglycemia. Place in the order the manner in which the nurse should provide evening care to the resident. All options must be used.

Identify the client using two identifiers. Assess the client's blood glucose level. Provide an evening meal. Assess percentage of the meal eaten. Administer 20 units of insulin aspart. Provide an evening snack. The order for the nurse to follow is to first identify the client using two identifiers, assess the client's blood glucose level, provide the client with an evening meal, assess the percentage of the meal the client has eaten, administer 20 units of insulin aspart, and provide an evening snack. This order will include assessments and prevent administering insulin if resident does not eat.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?

Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client. The nurse should notify the supervisor of the relationship with the client and ask to be reassigned. If no other nurse is immediately available, the nurse should provide the necessary care until another nurse can assume responsibility for the aunt's care. The other answers are incorrect because the nurse may not be able to ensure that the therapeutic nurse-client relationship can be maintained when caring for a family member.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be?

The nurse should ask the person to talk to the family directly. The nurse should ask the person to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the person for a learning session because doing so would be a breach of the client's right to privacy. Referring the person to a social worker is not an appropriate choice.

The nurse is caring for a client about to receive the first chemotherapy transfusion. When planning how to conduct the teaching session, what action would assist the nurse in determining the client's learning preferences?

asking the client which is preferred--brochure, video, or podcast The best way for the nurse to determine a client's learning preference is to ask questions relating to how the client likes to learn. For example, the nurse should ask the client if he or she prefers to read a brochure, watch a video, or listen to a podcast. Asking the client to read something would help the nurse determine the ability to read but not the client's learning preferences. Asking the client about education level and whether he or she likes to read might help the nurse determine at what level to present the information, but not about the client's learning preferences. Asking the client about literacy and/or health literacy may be viewed as insensitive by the client. Additionally, it would not provide the nurse with the client's learning preferences.

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation?

Create the client assignment by considering available staff's skill level and client needs. When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?

evaluation Although the nurse is assessing pain relief, this action is considered part of evaluation, not assessment, because the nurse is evaluating whether a performed intervention has met its goal. During the nursing diagnosis step of the nursing process, the nurse labels or describes the client's health condition or needs such as pain. During implementation, the nurse attempts to meet the client's needs through such interventions as administering medication.